104 10117 10075

104-10117-10075 SUPPLEMENTAL PERSONAL HISTORY STATEMENT

SECTION 1. INSTRUCTIONS

Submit in duplicate. Answer all questions completely. If question does not apply, write "NA." Write "UNKNOWN" only if you do not know the answer and it cannot be obtained from personal records. If additional space is required use extra pages the same size as this page and sign each such page. Reference each continued item by section and item number to which it relates.

  1. FULL NAME (last-first-middle): Flores, Daniel
  2. DATE OF BIRTH: 04 Aug 1935
  3. PLACE OF BIRTH (City, State, Country): San Marcos Texas
  4. SOC SEC NO.: 460-48-6230
  5. PRESENT STATUS (Single, widowed, divorced, or annulled) SPECIFY: Married
  6. STATE DATE, PLACE, AND REASON FOR ALL DIVORCES OR ANNULMENTS: "NA"

SECTION 11. SPOUSE

  1. NAME OF SPOUSE (last-first-middle-maiden): Flores, (Dorothy Arnett)
  2. DATE OF BIRTH: 31 Jan 1935
  3. PLACE OF BIRTH (spouse): Portland, Oregon
  4. DATE AND PLACE OF MARRIAGE: 18 November 1960 (Lima, Peru)
  5. CITIZENSHIP OF SPOUSE (If naturalized, indicate date & place of naturalization & certificate no.): USA

  6. STATE DATE, PLACE, AND REASON FOR ALL SEPARATIONS, DIVORCES OR ANNULMENTS: "NA"

  7. OCCUPATION: Legal Secretary

  8. PRESENT EMPLOYER: (Arnold and Porter)
  9. EMPLOYER'S OR BUSINESS ADDRESS (No., Street, City, State & Zip Code - Country if not U.S.): 1229 19th Street NW, Washington, D.C.

SECTION 111. RESIDENCE (Since date of last PHS, if overseas residence indicate only city and country)

ADDRESS LAST RESIDENCE FIRST (number, street, city, state, country) Ind. Apt. # INCLUSIVE DATES (month & year) FROM-TO
(Guayaquil, Ecuador) May 1969 May 1971
(Lima, Peru) Sept. 1971 Feb. 1974
Vienna, Va (8151 Larkin La.) Feb. 1974

SECTION IV. CHILDREN AND OTHER DEPENDENTS (Provide information for all children and dependents)

NAME RELATIONSHIP DATE & PLACE OF BIRTH CITIZENSHIP ADDRESS
(Kendra) Flores Daughter 3 March 1971 Washington, D.c. USA 8151 Larking La) Vienna, Va.
(Zola Marie) Flores Daughter 15 March 1974 Washington, D.C. USA "

SECTION V.

  1. NAME (Last-First-Middle): GUERRERO, Richard
  2. RELATIONSHIP: Nephew
  3. DATE OF BIRTH:
  4. PLACE OF BIRTH (City, State, Country): New Orleans, La
  5. CITIZENSHIP (Country): USA
  6. ADDRESS OR COUNTRY IN WHICH RELATIVE RESIDES: Ansbach, Germany
  7. EMPLOYED BY: U.S. Army
  8. FREQUENCY OF CONTACT: Periodic
  9. DATE OF LAST CONTACT: March 1974
  10. NAME (Last-First-Middle):
  11. RELATIONSHIP:
  12. DATE OF BIRTH:
  13. PLACE OF BIRTH (City, State, Country):
  14. CITIZENSHIP (Country):
  15. ADDRESS OR COUNTRY IN WHICH RELATIVE RESIDES:
  16. EMPLOYED BY:
  17. FREQUENCY OF CONTACT:
  18. DATE OF LAST CONTACT:
  19. NAME (Last-First-Middle):
  20. RELATIONSHIP:
  21. DATE OF BIRTH:
  22. PLACE OF BIRTH (City, State, Country):
  23. CITIZENSHIP (Country):
  24. ADDRESS OR COUNTRY IN WHICH RELATIVE RESIDES:
  25. EMPLOYED BY:
  26. FREQUENCY OF CONTACT:
  27. DATE OF LAST CONTACT:

SECTION VI. PERSONAL DECLARATIONS

  1. HAVE YOU BEEN ARRESTED, INDICTED, OR CONVICTED FOR ANY VIOLATION OF LAW (Other than for minor traffic violation) SINCE THE DATE OF YOUR LAST PHS: NO
  2. SINCE THE DATE OF YOUR LAST PHS. HAVE THERE BEEN ANY UNFAVORABLE INCIDENTS IN YOUR LIFE WHICH MIGHT REQUIRE EXPLANATION: NO

SECTION VI۱۰ PERSONS TO BE NOTIFIED IN CASE OF EMERGENCY

  1. NAME (Last-First-Middle): Same as previous PHS.
  2. RELATIONSHIP:
  3. HOME ADDRESS (Number, Street, City, State, ZIP Code):
  4. HOME TELEPHONE NUMBER:
  5. BUSINESS ADDRESS (Number, Street, City, State, ZIP Code) INDICATE NAME OF FIRM OR EMPLOYER, IF APPLICABLE:

  6. BUSINESS TELEPHONE NUMBER & EXT.:

  7. IN CASE OF EMERGENCY, OTHER CLOSE RELATIVES (spouse, mother, father ...) MAY ALSO BE NOTIFIED. IF SUCH NOTIFICATION IS NOT DESIRABLE BECAUSE OF HEALTH OR OTHER REASONS, PLEASE IDENTIFY THE PERSONS NOT TO BE NOTIFIED AND THE REASON.

SECTION VIII. ADDITIONAL REMARKS

29 March 1967 Daniel Flores

  1. NAME (First-middle-last): Daniel (nmn) Flores
  2. MARITAL STATUS: MARRIED
  3. NAME OF SPOUSE (First-middle(maiden)dast): Dorothy A. Moran Flores
  4. PLACE OF MARRIAGE: Lima, Peru
  5. DATE OF MARRIAGE: 18 November 1960
  6. RESIDENCE (Since date of last PHS, if overseas residence indicate only city & country)
  7. SINCE (Date): August 1961
  8. NUMBER AND STREET: 2828 Connecticut Ave., N.W.

  9. CITY AND STATE: Washington, D.C. 20008

  10. HAVE YOU BEEN ARRESTED, INDICTED.SOR CONVICTED FOR ANY VIOLATION OF LAW (Other than for minor traffic violation) SINCE THE DATE OF YOUR LAST PHS: NO

  11. SINCE THE DATE OF YOUR LAST. PHS, HAVE THERE BEEN ANY UNFAVORABLE INCIDENTS IN YOUR LIFE WHICH MIGHT REQUIRE EXPLANATION: NO

  12. NAME OF YOUR PRESENT IMMEDIATE SUPERVISOR: Harry T. Mahoney

  13. EXT: 7176

  14. RM: 3054

29 March 1967 Daniel Flores

LETURN PHS AND ATTACHMENTS 10 HEADQUARTERS